Practical Approach to Pediatric Constipation · 2019. 5. 3. · •Feeding pattern in infancy...
Transcript of Practical Approach to Pediatric Constipation · 2019. 5. 3. · •Feeding pattern in infancy...
“Practical Approach to Pediatric Constipation”Jennifer B. Webster, DO
POMA 111th Annual Clinical Assembly & Scientific SeminarMay 1-4, 2019
Practical Approach to Pediatric Constipation
Jennifer Webster, DO
Assistant Professor, Department of Pediatrics
Attending Physician, Division of Gastroenterology, Hepatology, and Nutrition
Children’s Hospital of Philadelphia
Disclosure
• I have no relevant financial relationships or conflicts of interest to disclose.
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Objectives
• Better understand the epidemiology and pathophysiology of pediatric functional constipation
• Appropriately choose medical work up for pediatric constipation
• Improve treatment of functional constipation in pediatrics
• Understand population required referral to pediatric gastroenterology
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“Practical Approach to Pediatric Constipation”Jennifer B. Webster, DO
POMA 111th Annual Clinical Assembly & Scientific SeminarMay 1-4, 2019
National Statistics
Prevalence around 30%
• 30-50% of children have symptoms for >5 years
5% of visits to the general pediatrician
25% of referrals to pediatric GI
60% of pediatricians report referring to GI for constipation
Estimated $3.9 billion of excess spending
• Outpatient, ED, Inpatient, Pharmacy
Epidemiology of childhood constipation: a systematic review. Am J Gastroenterol, 2006. 101(10)p. 2401-9.
Epidemiology and burden of chronic constipation. Can J Gastroenterol, 2011. 25 Suppl B: p.11B-15BHealth utilization and cost impact of childhood constipation in the United States. J Pediatr, 2009. 154(2): p. 258-62
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Epidemiology
• No difference in prevalence by gender
• Majority of patients are under 4 years of age at diagnosis
• In one major study
– No differences in:
• Water intake
• Feeding pattern in infancy
• Toilet training age
• Diet pattern
– Over 90% of patients have “functional idiopathic constipation”
Prevalence, Clinical Characteristics, and Management of Functional Constipation at Pediatric Gastroenterology
Clinics. J Korean Med Sci. 2013; 28: 1356-1361.#POMA19 #ChooseKnowledge
Healthcare Utilization
Health Utilization and Cost Impact of Childhood Constipation in the United States
Liem, Et al (Carlo DiLorenzo). Journal of Peds. 2009. Nationwide.
• Annual expenditure was significantly higher in children with constipation versus those without ($3430 vs $1099 per year) →cost attributable to constipation relative to the general pediatric population is approximately $3.9 billion
Direct medical costs of constipation in children over 15 years: a population-based birth cohort
Choung, et al. JPGN. 2012. Mayo.
• Mean direct medical costs were 4x those of controls ($25,100 vs $5,913)
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“Practical Approach to Pediatric Constipation”Jennifer B. Webster, DO
POMA 111th Annual Clinical Assembly & Scientific SeminarMay 1-4, 2019
Definition of Constipation
Rome criteria for child with developmental age <4 years
• Must have ≥ 2 of the following for ≥ 1 month
– ≤ 2 defecations per week
– At least 1 episode of incontinence per week after the acquisition of toilet training skills
– History of excessive stool retention
– History of painful or hard bowel movements
– Presence of a large fecal mass in the rectum
– History of large-diameter stools that may obstruct the toilet
Drossman DA, Hasler WL. Rome IV-functional GI disorders: disorders of gut-brain interaction. Gastroenterology. 2016;150(6):1257–1261.#POMA19 #ChooseKnowledge
Definition of Constipation
Rome criteria for child with developmental age ≥ 4 years
• Must have ≥ 2 of the following for ≥ 2 months with insufficient criteria for irritable bowel syndrome
– ≤ 2 defecations per week
– At least 1 episode of incontinence per week
– History of retentive posturing or excessive volitional stool retention
– History of painful or hard bowel movements
– Presence of a large fecal mass in the rectum
– History of large-diameter stools that may obstruct the toilet
Drossman DA, Hasler WL. Rome IV-functional GI disorders: disorders of gut-brain interaction. Gastroenterology. 2016;150(6):1257–1261.#POMA19 #ChooseKnowledge
Formation of Feces
• Enteric content enters the colon via the ileocecal valve
• Stools are formed by the progressive absorption of water
• Propelled along the colon to the rectum
– High amplitude propagating contractions
• Rectum stores and eliminates stool
Water
Water
Water
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“Practical Approach to Pediatric Constipation”Jennifer B. Webster, DO
POMA 111th Annual Clinical Assembly & Scientific SeminarMay 1-4, 2019
Pathophysiology of Defecation
• Stool in the rectum triggers the autonomic nervous system to relax the internal anal sphincter
• Stool comes in contact with receptors in the anal canal
• Somatic nervous system triggered to control external anal sphincter
• Act of defecating– Contract diaphragm, abdomen and
rectal muscles– Relax external anal sphincter– Relax puborectalis muscle
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Where is the problem?
• Colon
– Slow transit• Chronic constipation
– Neurogenic bowel
• Spinal cord anomalies
• Sacral teratoma
– Dysmotility
• Pseudo-obstruction
• Colonic inertia
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Where is the problem?
• Rectum and sphincters
– Internal anal sphincter• Hirschsprung disease
• Anal achalasia
– External anal sphincter (voluntary)
• Anal stenosis
• Disordered defecation
• Voluntary withholding
– Megarectum• Result of abnormal function of external sphincter
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“Practical Approach to Pediatric Constipation”Jennifer B. Webster, DO
POMA 111th Annual Clinical Assembly & Scientific SeminarMay 1-4, 2019
Diagnosis
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Age History(frequency and consistency of stool)
Physical
Newborn –4 months
• Passage of meconium• Change in diet• Blood in stool
• Abdominal exam (distention)• Perianal exam (anorectal malformations)• Digital rectal exam (passage of stool, tight)• Spine and tone (dimple/tuft of hair)• Hemoccult
5 months –Toilet training
• Change in diet• Passage of hard stool/pain with stools• Withholding behaviors• Success or failure of toilet training
• Abdominal exam (palpable stool)• Perianal exam (stool from leakage)• Digital rectal exam (stool in rectum)
School aged • Passage of hard stool/pain with stools• Toilet accessibility or phobia• Leakage of stool• Diet and water intake
• Abdominal exam (palpable stool)• Perianal exam (stool from leakage)• Digital rectal exam (stool in rectum)
Older children and teens
• Passage of hard stool/pain with stools• Recent infection• Change in routine or stressors• New medications• Leakage of stool• Diet and water intake
• Abdominal exam (palpable stool)• Perianal exam (stool from leakage)• Digital rectal exam (stool in rectum)
Withholding
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“Practical Approach to Pediatric Constipation”Jennifer B. Webster, DO
POMA 111th Annual Clinical Assembly & Scientific SeminarMay 1-4, 2019
Toilet TrainingEarly
(readiness; developmental)Middle
(self help; teachable)Late
(making progress)
• Understands potty words • Flushes toilet by self • Uses a regular toilet
• Shows interest in potty training
• Washes hands • Stays BM free during the day (no “accidents”)
• Tells during or after having a BM (and has regular BMs, not overnight*)
• Pulls training pants up/down
• Tells before having to urinate and stays dry during the day
• Indicates a physical need to “go”
• Enters bathroom to urinate or have a BM
• Stays dry for 2 hours • Stays dry overnight
Schum et al., 2002
Blum, et al. 20014
1. Children with constipation and withholding toilet train later2. Constipation contributes to stool toileting refusal
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Differential Diagnosis and Alarm Signs
• Hirschsprung disease– No passage of meconium >48 hours of age
– Onset <1 month of age
– Abdominal distention
– Malnutrition
– DRE: narrow canal, Elimination of stool after DRE
• Anorectal malformations– Ribbons stools
– DRE: tight canal
Management of chronic constipation in children. Symposium: Gastroenterology. Paediatrics and child health. 2015.
https://www.babymed.com/strange-pregnancies/imperforate-anus-anorectal-atresia#POMA19 #ChooseKnowledge
Differential Diagnosis and Alarm Signs
• Pseudo-obstruction– Malnutrition
– Abdominal distention
– Urinary involvement
• Spinal cord abnormalities– Weakness of legs
– Urinary involvement
– Gluteal cleft or tuft of hair
– DRE: absent anal and cremasteric reflex
https://radiopaedia.org/articles/colonic-pseudo-obstruction-1?lang=us
https://pediatricneurosurgery.org/diagnosis/tethered-spinal-cord
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“Practical Approach to Pediatric Constipation”Jennifer B. Webster, DO
POMA 111th Annual Clinical Assembly & Scientific SeminarMay 1-4, 2019
Less likely etiologies
• Cystic fibrosis
• Celiac disease
• Inflammatory bowel disease
• Sexual abuse
• Anorexia
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Work up
Laboratory investigation– No published data meet standards
to validate testing for:• Hypothyroidism
• Celiac disease
• Hypercalcemia
Abdominal x-ray
Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr, 2014. 58(2): p. 258-74.#POMA19
Work Up – Where is the problem?
Colon
• Slow transit
• Neurogenic bowel
• Dysmotility
1. Transit study
2. Colonic manometry
3. Lumbar spine MRI
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“Practical Approach to Pediatric Constipation”Jennifer B. Webster, DO
POMA 111th Annual Clinical Assembly & Scientific SeminarMay 1-4, 2019
Colonic Manometry
Fed state – increased activity After Bisacodyl – HAPCs propagating to the most distal recording port
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Work up – Where is the problem?
• Hirschsprung disease
• Anal achalasia
• Disordered defecation
1. Anorectal Manometry
2. Suction Rectal Biopsy
Internal and external anal sphincter
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Anorectal ManometryRectoanal inhibitory reflex RAIR) Push – Defecation Dynamics
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“Practical Approach to Pediatric Constipation”Jennifer B. Webster, DO
POMA 111th Annual Clinical Assembly & Scientific SeminarMay 1-4, 2019
- Ganglion cells not present
- Abnormal acetylcholinesterase staining
- Absence of calretinin staining
Koeppen & Stanton: Berne and Levy Physiology, 6th Edition 2008
Rectal Suction Biopsy
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Treatment
• Dietary
– Fiber
– Fluid intake
• Pharmacologic
– Softeners
– Osmotic laxatives
– Stimulant laxatives
– Rectal therapies
– Secretagogues
• Behavioral Therapy
– Cognitive behavioral therapy
• Biofeedback
• Surgery
– Antegrade enemas
– Ostomy
Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr, 2014. 58(2): p. 258-74.#POMA19 #ChooseKnowledge
Dietary Treatment
Fiber
• Limited evidence that additional fiber improves constipation compared to placebo
• NASPGHAN guidelines
– “Evidence does not support the use of fiber supplements in the treatment of functional constipation”
Fluid Intake• Increasing fluid alone has not been
shown to improve constipation
• Similar stool frequency in patients who increase water intake >50% to those who did not
• NASPGHAN guidelines
– “Evidence does not support the use of extra fluid intake in the treatment of functional constipation”
Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr, 2014. 58(2): p. 258-74.#POMA19 #ChooseKnowledge
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“Practical Approach to Pediatric Constipation”Jennifer B. Webster, DO
POMA 111th Annual Clinical Assembly & Scientific SeminarMay 1-4, 2019
Pharmacologic
Softeners/Lubricants Stimulant Laxatives
• Mineral Oil• Docusate
• Bisacodyl• Senna
Osmotic Laxatives Rectal Therapy
• Lactulose• PEG 3350• Magnesium products
• Glycerin• Mineral oil• Sodium phosphate• NaCl• Bisacodyl
❖ Polyethylene glycol as best evidence versus placebo for treatment of constipation❖ Lactulose is recommended of polyethylene glycol is not tolerated or <6 months❖ Avoid rectal therapies – especially if there is a fear component
Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr, 2014. 58(2): p. 258-74.#POMA19 #ChooseKnowledge
The Controversy of PEG 3350
• On February 14, 2017, a Philadelphia news station reported that multiple families approached them claiming that a brand of PEG product caused neuropsychiatric symptoms in their children
• Mass media reporting and patient beliefs about medications have a negative impact on adherence to medication
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“Practical Approach to Pediatric Constipation”Jennifer B. Webster, DO
POMA 111th Annual Clinical Assembly & Scientific SeminarMay 1-4, 2019
SecretagoguesLubiprostone Chloride channel activator → enhances
chloride-rich intestinal fluid secretion• Rates of response were
higher with lubiprostone vs placebo for improved pain and stool frequency
• Rates of response were higher with lubiprostone vs placebo for improved bloating and stool frequency
Linaclotide Guanylate cyclase-C agonist → increases luminal chloride and fluid secretion through the generation of cyclic guanosine monophosphate
Significantly greater percentage of linaclotidetreated patients vs placebo reported a reduction of ≥30% in abdominal pain
Behavioral Therapies
• Education
– “Poo in You”
• Relaxation training
– Deep exhales, increase belly pressure (pinwheels)
• Address anxiety and toilet phobia
– Gradual shaping
– Start with diaper/pull-up on toilet
• Bowel retraining
– Toilet sitting routine – sit 1 minute for each year up to age 10, after meals
– Unhurried time
• Reinforcement
– Simple schedules
– Immediate, tangible rewards focused to child’s interests
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Biofeedback
• Behavioral therapy such as biofeedback is more effective than medication alone
• Most helpful for patients with dyssynergic defecation
• No evidence in children at this time
Electrodes placed on lower abdomen and perianal area
Abnormal if unable to maintain perianal relaxation during increased abdominal pressure
Loening-Baucke V. Prevalence, symptoms and outcome of constipation in infants and toddlers. J Pediatr 2005; 146: 359-63.
Cheng, Lily, Goldstein, Allan. Surgical Management of Idiopathic Constipation in Pediatric Patients. Clin Colon Rectal Surg. 2018;31:89-98.#POMA19 #ChooseKnowledge
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“Practical Approach to Pediatric Constipation”Jennifer B. Webster, DO
POMA 111th Annual Clinical Assembly & Scientific SeminarMay 1-4, 2019
Surgical Management
Anal procedures
• Sphincter myotomy• Botox injection
Antegrade Colonic Enemas
• Appendicostomy• Cecostomy
Colorectal resection
• Segmental resection• Subtotal colectomy• Total colectomy
Intestinal diversion
• Ileostomy• Colostomy
Cheng, Lily, Goldstein, Allan. Surgical Management of Idiopathic Constipation in Pediatric Patients. Clin Colon Rectal Surg. 2018;31:89-98
Siminas S, Losty PD. Current surgical management of pediatric idiopathic constipation: a systamtic review of published studies. Ann Surg 2015;262(06):925-933.
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Surgical Management
• Anal botox– For patients with increased tone of the sphincter or voluntary withholding– Treatment of choice for anal achalasia
• Antegrade enemas (ACE)– Recommended for intractable constipation refractory to medical management – Average success rate of 82% for reducing soiling– Colonic manometry often required before placement
• Colorectal resection– Reserved for patients with segmental abnormalities– Short term improvement with potential complications– May be more effective with placement of ACE
• Diversion– Temporary to decreased colonic dilatation and improve motility
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Antegrade Enemas
Complications:• Pain• Granulation tissue• Stoma leakage• Stoma stenosis• Infection
Complications:• Tube leakage• Granulation
Malone Appendicostomy (ACE) Surgical Cecostomy
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“Practical Approach to Pediatric Constipation”Jennifer B. Webster, DO
POMA 111th Annual Clinical Assembly & Scientific SeminarMay 1-4, 2019
Surgical Management Outcomes
• Maintain continence
• Decrease colonic dilatation
• Return of colonic motility after improved dilatation #POMA19 #ChooseKnowledge
Referral to Pediatric Gastroenterology
• Common reasons for referral– Parental pressure– Concern for missing another diagnosis – Failure of initial therapy
• Variability in background knowledge– 8% of general pediatricians aware of the NASPGHAN guidelines– 60% of general pediatricians aware of the Rome criteria to define functional constipation
• Discomfort with care of these patients– 40% of trainees referred because they did not feel comfortable with management of
these patients– >50% felt there was not enough childhood constipation-related information available
Variability in the Management of Childhood Constipation. Dean Focht III, Raymond Baker, James Heubi, M.Susan Moyer. Clinical Pediatrics. 2006. Cincinnati.
Knowledge and Practice Styles of Pediatricians in Saudi Arabia Regarding Childhood Constipation. JPGN. 2013. #POMA19 #ChooseKnowledge
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“Practical Approach to Pediatric Constipation”Jennifer B. Webster, DO
POMA 111th Annual Clinical Assembly & Scientific SeminarMay 1-4, 2019
NASPGHAN Guidelines
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Who should be referred?
• Red flag symptoms– Delayed passage of meconium
– Onset < 1 month of age (without a trigger)
– Malnutrition
– Abnormal digital rectal exam
• Lack of response after escalation of therapy
• Need for advanced work up or treatment– Evidence of disordered defecation → anorectal manometry
• Biofeedback
– Concern for dysmotility→ colonic manometry• Surgical interventions
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Summary
• Pediatric constipation is common and expensive• The most important part of diagnosis is the history and physical• Work up can be extensive but often the HPI alone is enough
– Determine work up based off of primary location of concern
• Treatments include– Diet– Medication– Behavioral Therapy and Biofeedback– Surgical
• Referral for patients who have failed typical therapy or may require advanced work up
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“Practical Approach to Pediatric Constipation”Jennifer B. Webster, DO
POMA 111th Annual Clinical Assembly & Scientific SeminarMay 1-4, 2019
Patient Resources
• How to Potty Train Your Monster • I can't! I won't! No way!
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Questions?
• Feel free to reach out!
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